Cuba has one of the best healthcare systems in the world… but it pays doctors €46 a month

Fergal Browne explores the two sides of the Revolution’s biggest talking point.

“NOTHING IS EVER sufficient for a mother of a daughter with problems,” says Ana Mahe Inda, her voice growing more resolute.

But the attention that my first child received has been nothing short of spectacular.

Ana’s first daughter, Amalie, was born with Wolf-Hirschhorn syndrome meaning from the moment of birth, Amalie had complications with her heart, kidneys and facial features.

“Immediately we were sent to specialists in different medical areas. Week after week they worked to resolve each and every problem she had. Never once did we lack a thing or have to pay for anything even though a lot of this was really expensive medicine,” says Ana who is the director of a photography school in central Havana, Cuba.

“I looked online to see how much the treatment Amalie received would cost in the United States; $100,000 dollars apparently and here it cost nothing thanks to the revolution,” says Tomas Inda, Amalie’s grandfather.

The early detection of Amalie’s syndrome, at six months pregnant, is thanks to Cuba’s extensive Maternal-Infant programme, first introduced post-1959 revolution, which has seen the Caribbean country fall to the second-lowest child mortality rate in the Americas, 20% lower than that in the United States.

Ana describes the Maternal-Infant Programme as ‘tenacious’.

They send you to do ultrasounds, psychologists, absolutely everything day after day and it’s obligatory. If you miss an appointment, someone will come to your door and bring you to the appointment. You don’t have a choice.

A study for the International Journal of Epidemiology entitled ‘Health in Cuba’ says the work of Cuba with regards child survival shows how ‘a continuum of care that provides for the pre-conceptual health of women, prenatal care, skilled birth attendants, and a comprehensive well-baby programme can quickly reduce infant mortality to levels approaching the biological minimum’.

Transformation

Cuba’s health system was transformed as a result of the 1959 revolution led by Fidel Castro. Previously, it ran a dual private-public health system with around 6,000 physicians, two-thirds of which operated in Havana.

Many of the older generation have terrible memories of the system.

“I remember my appendix exploded at five years old and waited 48 hours in absolute pain to be attended to and nobody came,” says Inda, whose parents were poor peasants from rural Cuba.

The public health service was terrible and we couldn’t afford the private. My father had to plead and guarantee his vote to a local politician to get me the operation that saved my life.

Cuba nowadays has a cost-free public health service, which boasts the third-highest doctor-patient ratio in the world with 70,000 trained medics (at any one time though about 20% of which are on international missions abroad meaning the ratio on the ground is actually lower), a life expectancy rate which is the second highest in the Americas and in 2015 became the first nation in the world to officially eliminate the transfusion of HIV from mother to child.

The Director-General of the World Health Organisation, Margaret Chan, said in 2014 “we sincerely hope that all of the world’s inhabitants will have access to quality medical services, as they do in Cuba”.

Preventative Healthcare

Cuba’s system prioritises prevention of disease and illness over curing once an illness occurs. Specifically, this involves aggressively targeting suspected outbreaks of diseases, free healthcare and ease of access for all no matter what their location.

The long-term sick and elderly are visited by GPs in their homes, free buses are put on so people from rural areas can visit hospitals in the capital, while health representatives regularly knock on the doors of houses asking if anyone is sick. If there is someone ill, they are immediately booked in for an appointment.

“Cuba’s success in international statistics like infant mortality is because it’s a coordinated system organised from one point of the island to the other guaranteeing free and accessible health whether it is primary, secondary or tertiary care to all citizens”, says Dr Antonio Copo, Head of the Transplant department in Havana’s Hermanos Almeijeiras hospital.

Ease of access is given by the country’s 440 policlinicos (local health centres with specialists in various health areas) and family practices, which are coordinated from the policlinicos.

“This policlinico attends to a population of 27 thousand inhabitants with 24 GP practices evenly spread around the community so that no citizen lives more than 500 metres from their family doctor”, says Dr. Marieta Ramirez, Head of Education and Investigation at the policlinico 26 de Julio in western Havana.

The policlinico 26 de Julio

“A family doctor is governed by two fundamental pillars; the first to treat the patient correctly and the second to correctly analyse the principal problems in their area which could, for example, be biological or environmental. The findings are then reported to a health official who decides the appropriate action,” adds Ramirez.

This structure and emphasis on GP reported trends is seen as an essential reason why Cuba, a tropical nation, has had much success in eradicating infectious diseases like dengue.

“If evidence appears that an infectious disease may be spreading, the area will be immediately fumigated,” says Ramirez.

Largely due to that success in combating dengue, Cuba is one of the few countries in the Americas yet to have a citizen contract another mosquito-spreading disease, Zika.

The Caribbean nation has also invested heavily in a biotechnology sector, mainly to counteract the inability to buy drugs cheaply due to the American blockade, which has seen the state develop vaccines little used elsewhere, including one for lung cancer.

‘The operative principles are relatively straightforward: once a safe and effective vaccine becomes available, the entire at-risk population is immunised; if a vaccine is not available, the susceptible population is screened and treated; where an arthropod vector can be identified, the transmission pathway is disrupted by mobilising the local community which in turn requires effective neighbourhood organisation and universal primary health care’, says the International Journal of Epidemiology study.

Criticisms

Critics of Cuba point out that it’s easy to sustain such a high number of doctors in a primary-care focused system when salaries are so poorly paid, therefore unrealistic in other countries.

The average Cuban physician receives 1,400 Cuban pesos (€46) per month, and faces restrictive rules allowing them to leave the country meaning few can travel abroad unless sent on state-sponsored missions abroad. The latter, though, has since been relaxed somewhat in line with more liberal reforms introduced since Raul Castro became President of Cuba.

Most Cuban doctors interviewed were reticent about criticising the state, but expressed hope that salaries would rise as a result of economic benefits that come from the potential lifting of the United States-imposed blockade.

“The salary is so low that it doesn’t allow you do all the things you want to do. For example, if you want to eat, you can’t think about buying clothes. It allows you to survive, that’s all,” says Dr Wilfrido Munos, a dentist from the capital.

Dr Munos

As well as that, Cuban authorities greatly restrict access to health facilities meaning it was difficult to independently verify the actual state of health facilities. All patients interviewed expressed satisfaction with health services but doctors pointed to gaps.

“We continue to show really important statistics with regards mortality but there’s many things that are not OK,” says Dr Elena Alfonso Vereira, a surgeon.

In a lot of hospitals they’ve just abandoned maintenance for a long time.

The more official state line blames the US embargo for shortcomings.

Dr Antonio Copo

“It’s a reality that some hospitals have more resources than others, but you have to understand that this country is living under a blockade of more than 50 years. There’s limitations as a result,” says Dr Copo.

All we can do is share the little we have between everyone as best we can.

Despite these criticisms many Cubans say they feel secure with regards their health. A 2006 independent poll commissioned by Gallup showed three quarters of Cubans expressed satisfaction with the health system.

“We Cubans know that if a precarious health situation arises, the doctors will resolve it. This security is what we Cubans breath’, says Orlando Padron, an engineer, who recently had a hernia operation.

“I don’t have any fear for the future. Hopefully with improved relations with the United States, it will mean more products and medicine getting to Cubans who need them. I’ve no worry for the future because the Cuban government has always put the health of Cubans first,” he says proudly.

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